SMFM Issues New Guidance on Diagnosing and Managing Heart Failure During Pregnancy and Postpartum

Heart disease is a leading cause of pregnancy-related deaths in the U.S. 

Washington, DC – Prepregnancy counseling, assembling multidisciplinary care teams, and referring to centers with expertise are critical in managing pregnant patients with heart failure to optimize maternal and newborn health outcomes, according to new guidance issued by the Society for Maternal-Fetal Medicine (SMFM). Consult Series #73, Diagnosis and management of right and left heart failure during pregnancy and postpartum, outlines recommendations for physicians on counseling and managing patients with heart failure.   

Heart disease is a leading cause of pregnancy-related deaths in the U.S., a disproportionate percentage occurring among non-Hispanic Black individuals. Heart failure, a syndrome in which the heart is unable to pump blood effectively, is a major contributor to maternal morbidity and mortality. Heart disease in pregnancy, including heart failure, increases the risk of low birthweight, lower Apgar scores, premature birth, and death. 

“Heart disease is a leading cause of maternal deaths, and it’s a growing problem,” said Arthur Jason Vaught, MD, a maternal-fetal medicine subspecialist and critical care physician at Johns Hopkins Medicine, and a member of the SMFM Publications Committee. “This new guidance focuses attention on heart failure in pregnancy so that we can improve both short- and long-term quality of life for our patients. Getting accurately diagnosed and treated for heart disease, either before pregnancy or early in pregnancy, is both life-prolonging and life-changing if caught early.”  

The new SMFM recommendations focus on treating pregnant patients with reduced ejection fraction (HFrEF) heart failure. Symptoms of heart failure include shortness of breath and fatigue, which can be normal symptoms of pregnancy. Heart failure can affect the heart’s left ventricle, right ventricle, or both. The treatment for heart failure in pregnancy depends on which ventricle is impacted, whether it is acute or chronic, and other individual health factors.  

Recommendation highlights: 

Counseling 

• Patients with known heart failure, regardless of disease severity, should receive preconception or early pregnancy consultation to categorize individual risk and identify possible maternal and perinatal health risks resulting from cardiovascular disease.
• Patients with severe pulmonary arterial hypertension and severe left ventricular dysfunction (EF < 30%) should be offered abortion care. Patients deciding to continue pregnancy should be supported at specialized centers with Pregnancy Heart Teams.
• Decisions about future pregnancies in patients with a history of peripartum cardiomyopathy should be individualized. Patients with fully resolved heart failure should be made aware of recurrence rates and severity if recurrence occurs. 

Medications and Treatment 

• Certain medications should be discontinued for patients planning a pregnancy or who are already pregnant, including sodium-glucose cotransporter inhibitors (SGLT2i), spironolactone, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and angiotensin receptor-neprilysin inhibitors (ARNi), and replaced with alternatives, such as hydralazine. Patients should discuss all medication changes with their care provider.
• Beta-blockers such as metoprolol, carvedilol, and bisoprolol should be continued.
• ACEi, ARB, aldosterone antagonists, and sodium-glucose cotransporter inhibitors (SGLT2i) should be used with caution while breastfeeding because of the potential risk to the newborn. 

Delivery 

• Delivery planning for patients with heart failure begins with identifying the health care team, which may include obstetrics, maternal-fetal medicine, cardiology, anesthesiology, nursing, and others.
• Delivering at term should be the goal in most uncomplicated patients, with vaginal delivery preferred unless cesarean is needed for obstetric indications. 

Postpartum Care 

• Many maternal cardiovascular deaths and severe illnesses occur after hospital discharge following delivery. Postpartum patients with heart failure require close monitoring due to the substantial and rapid changes in the cardiovascular system after giving birth.
• Postpartum patients with heart failure should receive routine counseling about infant feeding, and all medications should be reviewed for their compatibility and safety with breastfeeding.  

SMFM Consult Series #73 is supported by The Heart Rhythm Society and is published in PREGNANCY.

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About SMFM 
The Society for Maternal-Fetal Medicine (SMFM), founded in 1977, is the medical professional society for obstetricians who have additional training in high-risk, complicated pregnancies. SMFM represents more than 6,500 members who care for high-risk pregnant people and provides education, promotes research, and engages in advocacy to reduce disparities and optimize the health of high-risk pregnant people and their families. SMFM and its members are dedicated to optimizing maternal and fetal outcomes and assuring medically appropriate treatment options are available to all patients. 

Contact: Greg Phillips, Director of Communications, press@smfm.org